The New York Workers’ Compensation Drug Formulary (Drug Formulary) is based on a medication’s effectiveness and appropriateness for treatment of illnesses and injuries covered under the New York Workers’ Compensation Law.
This article explains when prior authorization is required for prescriptions and outlines the process for submitting Medication PARs through OnBoard.
When to Request Prior Authorization
Drugs listed on the Drug Formulary do not require prior authorization.
Providers must request prior authorization from the insurance carrier or self-insured employer to prescribe/dispense drugs in all of the following circumstances:
- Drugs not listed on the Drug Formulary
- Brand-name drug when a generic is available
- Combination products not listed
- Brand-name drugs when a generic with the same active ingredient is sold in another strength/dose
- Compounded drugs
If prior authorization is not obtained before dispensing, the payer can deny payment.
Formulary Phases & Special Considerations for Dispensing without Prior Authorization
The New York Workers’ Compensation Drug Formulary (Drug Formulary) divides medications into three categories. Prior authorization is not required when dispensed within the following limits:
- Phase A: Within 30 days of injury or until the claim is accepted/established (maximum 30-day supply)
- Phase B: After 30 days or once the claim is accepted/established (maximum 90-day supply)
- Perioperative Period: 4 days before and 4 days after surgery
Special Considerations
There are exceptions to the rule above which include the following:
- 7-day supply only: One time, up to 7-day prescription allowed without prior authorization (often applies to controlled substances)
- Prescribed course: Dispense full treatment course as written (e.g., antibiotics)
- Short-acting only: Only the short-acting version may be prescribed
- Clinically indicated: May prescribe if no MTG applies to the accepted condition or related complication (e.g., post-surgical infection)
How to Request Prior Authorization (Medication PAR)
Providers submit Medication Prior Authorization Requests (Medication PARs) via OnBoard, which includes up to three review levels.
Level 1 Review
After submitting a Medication PAR on OnBoard, Level 1 review follows the following requirements and timelines:
- The PAR must include the quantity prescribed, the number of refills, or the treatment duration (which cannot exceed 365 days).
- The insurer, self-insured employer, or pharmacy benefits manager must approve, partially approve, or deny the request within 4 days of submitting the PAR.
- A partial approval allows the medication but may limit the duration, quantity, or refills requested.
- If no response is received within 4 days, the request may be deemed approved (up to 365 days) by Order of the Chair.
- Any denial or partial approval must include a specific reason tied directly to the PAR.
Level 2 Review
Within 10 days or a Level 1 denial or partial approval, the provider may request a Level 2 review from the insurer’s physician.
Level 2 review is subject to the following requirements and timelines:
- The Medication PAR must include additional clinical justification addressing the reasons for the Level 1 denial or partial approval.
- The insurer’s physician must approve, partially approve, or deny the request within 4 calendar days of submission.
- If no response is received within 4 days, the request may be deemed approved (up to 365 days) by Order of the Chair.
Level 3 Review
Within 10 days of a Level 2 denial or partial approval, the provider may request a Level 3 review by the Workers’ Compensation Board (WCB) Medical Director’s Office.
Level 3 review is subject to the following requirements and timelines:
- The provider must include a response to the insurer’s stated reasons for denial or partial approval.
- Reviews may be handled by URAC-accredited or Board-approved entities with no conflicts or interests.
- The Medical Director’s decision is final and binding on all parties.
- A provider may only resubmit a Medication PAR for the same drug if the injured worker’s condition changes, making the prior denial no longer applicable.
For more information, providers can review the New York Workers’ Compensation Board (WCB) website.
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